MyChart - Breast Milk Donation Form

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Thank you for your interest in donating breastmilk. By completing this form, you will be initiating the process to donate breastmilk to the WakeMed Mothers' Milk Bank. Your generous donation will directly benefit NICU babies all along the east coast.

Step 1: Complete this online Breast Milk Donation Form

Step2: Log into your Active WakeMed My Chart account, please fill out the pre-screening questionnaire by following these steps:

a. Click or tap on the Menu button at the upper-left
b. Search for "questionnaires"
c. Click or tap the "Milk Bank Pre-Screening Questionnaire"
d. Complete the questionnaire.

Step 3: Receive a call from our Donor Intake Coordinator

Step 4: Complete Donor Intake Forms

-More in-depth questionnaire
-Donor Consent Form
-Release form(s) that give us permission to reach out to your doctor(s)

Step 5: Have blood drawn at a WakeMed or LabCorp location

Step 6: Become an approved milk donor and make your first donation!

Please expect to hear from us within 7-14 days. If you have any questions, please feel free to contact us directly by calling 919-350-8599, option 1 or emailing us at mothersmilkbank@wakemed.org.

Please note, WakeMed Mothers' Milk Bank is not affiliated with any third party organization for compensation of your voluntary donation of breastmilk.

First Name

Last Name

Name you prefer to be called. (If same as first name, leave blank)

Preferred Pronouns

Email Address

Phone Number

Can we leave a voicemail at this number?

Street Address

Apt

City

State

Zip

Do you speak English?

If no, preferred language

Donor Date of Birth

Baby Date of Birth

Is your baby currently living?

Have you donated with us before?

Approximately how many ounces do you have to donate?

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